Provider Demographics
NPI:1407239585
Name:MARTIN, STACY (LPC, LAC, CACI)
Entity Type:Individual
Prefix:
First Name:STACY
Middle Name:
Last Name:MARTIN
Suffix:
Gender:F
Credentials:LPC, LAC, CACI
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:301 HALTON RD STE F
Mailing Address - Street 2:
Mailing Address - City:GREENVILLE
Mailing Address - State:SC
Mailing Address - Zip Code:29607-3498
Mailing Address - Country:US
Mailing Address - Phone:864-479-4226
Mailing Address - Fax:
Practice Address - Street 1:301 HALTON RD STE F
Practice Address - Street 2:
Practice Address - City:GREENVILLE
Practice Address - State:SC
Practice Address - Zip Code:29607-3498
Practice Address - Country:US
Practice Address - Phone:864-479-4226
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-07-07
Last Update Date:2023-08-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC454101YA0400X
SC1802226101YA0400X
SC6779101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)